Nyirö et al.

Chiropractic & Manual Therapies (2017) 25:24

DOI 10.1186/s12998-017-0154-y

RESEARCH Open Access

Exploring the definition of «acute» neck

pain: a prospective cohort observational
study comparing the outcomes of
chiropractic patients with 0–2 weeks,
2–4 weeks and 4–12 weeks of symptoms
Luana Nyirö1,2*, Cynthia K. Peterson1,2 and B. Kim Humphreys1,2

Abstract
Background: Neck pain is a common complaint in chiropractic patients. Amongst other baseline variables, numerous
studies identify duration of symptoms as a strong predictor of outcome in neck pain patients. The usual time frame
used for ‘acute’ onset of pain is between 0 and 4 weeks. However, the appropriateness of this time frame has been
challenged for chiropractic low back pain patients. Therefore, the purpose of this study was to compare outcomes in
neck pain patients with 0–2 vs 2–4 and 4–12 weeks of symptoms undergoing chiropractic treatment.
Methods: This is a prospective cohort observational study with 1 year follow-up including 495 patients whose data
was collected between October 2009 and March 2015. Patients were divided into high-acute (0–2 weeks), mid-acute
(2–4 weeks) and subacute (4–12 weeks) corresponding to duration of their symptoms at initial treatment. Patients
completed the numerical pain rating scale (NRS) and Bournemouth questionnaire for neck pain (BQN) at baseline. At
follow-up time points of 1 week, 1 month, 3 months, 6 months and 1 year the NRS and BQN were completed along
with the Patient Global Impression of Change (PGIC) scale. The PGIC responses were dichotomized into ‘improved’ and
‘not improved’ patients and compared between the 3 subgroups. The Chi-square test was used to compare improved
patients between the 3 subgroups and the unpaired Student’s t-test was used for the NRS and BQN change scores.
Results: The proportion of patients ‘improved’ was only significantly higher for patients with symptoms of 0–2 weeks
compared to 2–4 weeks at the 1 week outcome time point (p = 0.015). The NRS changes scores were significantly
greater for patients with 2–4 weeks of symptoms compared to 4–12 weeks of symptoms only at 1 week (p = 0.035).
Conclusions: The time period of 0–4 weeks of symptoms as the definition of “acute” neck pain should be maintained.
Independent of the exact duration of symptoms, medium-term and long-term outcome is favourable for acute as well
as subacute neck pain patients.
Trial registration: Not applicable for prospective cohort studies. Ethics approval prior to study EK 19/2009.
Keywords: Neck pain mechanical, Treatment outcome, Chiropractic, spinal manipulative therapy, Acute

* Correspondence: luana.nyiroe@bluewin.ch
1
Department of Chiropractic Medicine, Orthopaedic University Hospital
Balgrist, Forchstrasse 340, 8008 Zürich, Switzerland
2
University of Zurich, Rämistrasse 71, 8006 Zürich, Switzerland

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Nyirö et al. Chiropractic & Manual Therapies (2017) 25:24
Background
The International Association for the Study of Pain de-
fines pain as “an unpleasant sensory and emotional ex-
perience associated with actual or potential tissue
damage or described in terms of such damage” [1]. Neck
pain is a common complaint throughout the world and
experienced by people of all ages, including children and
adolescents [2]. In the Global Burden of Disease 2010
study, neck pain is ranked the fourth leading cause of
disability (measured in years lived with disability (YLDs)
with an estimated global age-standardised point preva-
lence of neck pain around 4.9% [3], with about 50% of
the patients experiencing persistent pain after 1 year [4].
Even though the age and sex distribution across regions
is quite similar, slightly more women (5.8%) than men
(4.0%) seem to suffer from neck pain [3]. However, the
prevalence estimates of different studies show remark-
able heterogeneity [2, 3, 5–9]. These variations are most
likely caused by diversity in the case definition (i.e. dur-
ation of symptoms, anatomical location), inclusion/ex-
clusion criteria and variations in population [3, 5]. Most
studies estimate a 12-month prevalence between 30% to
50% in the adult general population with a prevalence
peak in middle age [5, 9–11]. The high incidence of neck
pain in the general population and the associated dis-
tress make neck pain patients common recipients of
medical and chiropractic treatment. In chiropractic prac-
tice, neck pain patients are second only to low back pa-
tients in their frequency [10, 12, 13].
The disability and economic costs associated with neck
pain have a large impact on individuals, their families,
healthcare systems and businesses [5, 8, 14, 15]. Calculating
the exact health costs is not straightforward. Costs vary de-
pending on the severity of symptoms and the duration of
work absence. For a specific calculation, several factors have
to be considered and the effective costs are divided into dir-
ect costs by detection, treatment, rehabilitation and preven-
tion of the disease and indirect costs caused by disability,
absence from work or loss of productivity in an employee
while they are at work [8, 14]. With longer duration of
symptoms and therefore often associated work absentee-
ism, indirect costs rise. Borghouts et al. [16] estimated that
in 1996, The Netherlands spent 1% of their total health care
expenditures on neck pain. Of this only 23% were direct
costs, while indirect costs amounted to 77% [16].
As a non-invasive treatment method, chiropractic, in-
cluding both spinal manipulative therapy (SMT) and
mobilization, is suggested as effective therapy for neck
pain by recent research [9, 17–19]. Certain medical pro-
fessionals tend to be concerned about the safety of SMT
to the cervical spine, considering a possible damage to the
vertebral artery. However, recent research found no evi-
dence of increased risk of vertebral artery injury compared
to other primary care physicians [20–22]. Bryans et al.
Page 2 of 10
[17] recommend a multimodal approach such as a com-
bination of SMT or mobilization and exercise, massage,
patient education etc. for treatment of both acute and
chronic neck pain.
Aware of the need for a standardized categorization that
could improve prediction of treatment outcome and allow
better targeting of care, recent spinal pain research has in-
creasingly been addressing the identification of specific
patient subgroups which may have more or less favourable
outcomes [23–25]. There have been several studies con-
ducted with the purpose to identify predictors for treat-
ment response of neck pain patients to chiropractic SMT
[12, 26–32]. All of these projects conclude the necessity to
find more specific definitions and subgroups for neck pain
patients, as the large heterogeneity makes comparing dif-
ferent studies a major challenge.
There are various ways to subdivide neck pain patients
including gender, age, type of onset, aetiology (mechanical
or neuropathic), severity or duration of symptoms. Accord-
ing to The International Association for the Study of Pain,
chronic pain is defined as pain which persists past the usual
time of healing [1]. Among different ways of categorization,
duration of symptoms might even be the strongest pre-
dictor of treatment outcome [9]. Various studies found
shorter duration of neck pain a predictor of a favourable
outcome in neck pain patients [26, 27, 29], while similar
studies discussing low back pain also demonstrated the im-
portance of duration and extent of symptoms [33, 34].
However, there is no consistent definition in the literature
relating to the time frames used to categorize patients since
onset of pain [35]. While most clinical studies agree
about the time cut-off point for “chronic” patients at
>3 or >6 months [1, 36], categorisation of “acute”
neck pain varies widely from <1 week [19], <3 weeks
[28], <4 weeks [19, 27, 29], <6 weeks [9] or even lon-
ger [23]. However, it is unknown if patients in these
various ‘acute’ categories have similar outcomes when
receiving similar treatments. Peterson et al. [29]
stated that acute neck pain patients (0–4 weeks of
symptoms) have higher pain levels and disability
before chiropractic treatment but improve faster
within the first 3 months compared to chronic pa-
tients (> 3 months of symptoms). At the same time,
early improvement after initial treatment has been
shown to be a strong positive predictive factor for a
favourable treatment response also in chronic neck
pain patients [29]. Similar results were found investi-
gating predictors of improvement in patients suffering
from low back pain [37–39]. However, in acute chiro-
practic patients treated for low back pain the time
frame for categorizing an ‘acute’ onset as 0–4 weeks
has recently been challenged [40].
Assuming that the duration of symptoms has a relevant
influence on the patient response to the treatment, it is
Nyirö et al. Chiropractic & Manual Therapies (2017) 25:24
necessary to develop a consistent definition regarding the
term “acute” in neck pain research. This may lead to more
specific and targeted treatments for certain patients, par-
ticularly relating to possible psychosocial factors. To find a
more accurate onset of symptoms categorization, the
current 0–4 week predefinition of the “acute” subgroup in
neck pain patients needs to be investigated.
In a study of low back pain patients receiving chiro-
practic treatment, differences in outcome within the
acute subgroup were reported and the common defin-
ition of acute low back pain lasting 0–4 weeks was chal-
lenged by suggesting it was too long [40]. The purpose
of this study is to explore whether or not the time frame
of 0–4 weeks in terms of the definition of “acute” for
neck pain patients is determined accurately. Therefore,
the objective of this study is to investigate whether or
not symptom duration of 0–4 weeks as the definition of
‘acute’ for neck pain patients has the strongest associ-
ation with outcomes in chiropractic patients compared
with other time frames.
Methods
This is a follow-up study to the prospective cohort study
“Predictors of outcome in neck pain patients undergoing
chiropractic care: comparison of acute and chronic pa-
tients” [29]. It is designed as a prospective cohort obser-
vational study with long-term follow-up up to 1 year
post treatment. Data was collected between October
2009 and March 2015.
Patients
Chiropractic practices in Switzerland were asked to con-
tribute patients to this study and 81 of the 260 Swiss
chiropractors participated. Selection criteria were pa-
tients with age over 18, neck pain of any duration and
no chiropractic or manual therapy in the prior 3 months.
Patients with contraindications to chiropractic manipu-
lative therapy in the form of specific pathology were ex-
cluded. These included acute fractures, tumours,
infections, inflammatory arthropathies, Paget’s disease,
anti-coagulation therapy, cervical spondylotic myelop-
athy, known unstable congenital anomalies and severe
osteoporosis. For this study, only the data from patients
with symptoms between 0 and 12 weeks were used
resulting in a sample size of 495 patients. It is unknown
what proportion of patients asked to participate in this
study by their chiropractors actually agreed.
Baseline data
For collecting the patient data, notification and instruc-
tion about the study and the study protocol were sent to
all of the 260 active members of the Association of Swiss
Chiropractors. During the annual mandatory postgraduate
continuing education convention (CE), verbal instructions
Page 3 of 10
outlining the study protocol were given and workshops on
the use of outcome measures in clinical practice were con-
ducted by one of the authors. The convention was held
promptly prior to the start of data collection with a re-
quest to all active members of the association to recruit
patients for this study.
Given this was a pragmatic study, no standardized
treatment plan or treatment number was given. The chi-
ropractors were especially asked not to change their
treatment methods and there were no specific treat-
ments excluded. However, 76% to 100% of the Swiss
Chiropractors use “diversified” technique as one of their
primary treatments [41]. Other commonly used add-
itional treatments include advice on the activities of daily
living, trigger-point therapy, therapeutic exercises, and
mobilization techniques [41].
Clinical and demographic baseline data about the pa-
tients was provided by the treating chiropractor, includ-
ing patient age, sex, marital status, paid employment,
onset of pain due to trauma or not, the patient’s general
health status, associated dizziness, whether or not the
patient smokes, current pain medication, duration of
complaint, number of previous episodes and if there
were signs and symptoms of cervical radiculopathy.
Prior to the initial treatment, each patient was re-
quested by the office staff of the practice to complete a
questionnaire assessing their individual impairment, in-
cluding the numerical rating scale (NRS) for neck pain
and a separate NRS for arm pain where 0 = no pain and
10 = the worst pain imaginable. Additionally, patients
completed the Bournemouth Questionnaire for neck dis-
ability (BQN), which has been translated and validated
into the German language [42].
Outcome measures
For the assessment of outcome, data from the NRS
(neck and arm separately), BQN and Patient Global Im-
pression of Change (PGIC) scale [43] were collected.
The PGIC is a self-report measure and reports the pa-
tient’s perception of the efficacy of treatment. The pa-
tient rates his individual impression of overall change on
a 7 item scale including the responses “much better”,
“better”, “slightly better”, “no change”, “slightly worse”,
“worse” and “much worse” [43, 44] (primary outcome
measure). The PGIC was dichotomized into ‘improved’
and ‘not improved’ patients. The responses ‘much better’
and ‘better’ were considered ‘improved’ and all other re-
sponses ‘not improved’.
One week, 1 month, 3 months, 6 months and 1 year
after the initial treatment, the patients were questioned
via telephone interviews about their treatment response.
The interviews were conducted by trained research as-
sistants blinded to patient or referring chiropractor iden-
tity. The time frame when each telephone call should be
Nyirö et al. Chiropractic & Manual Therapies (2017) 25:24
done was strictly limited (i.e. 6–8 days for 1 week data)
[29]. Thus, not every patient could be reached for the
telephone interview during the predefined time period
but remained in the study if other time periods con-
tained valid data.
Statistical analysis
According to the duration of symptoms, the patients
were divided into three subgroups of high-acute (0–
2 weeks of symptoms) (N = 274), mid-acute (2–4 weeks
of symptoms) (N = 62), and subacute (4–12 weeks of
symptoms) (N = 159). The available statistical power
varied depending on the subgroups being compared and
the dependent variable being used. For example, a con-
trast between the 274 high-acute and 159 sub-acute pa-
tients would have had 80% power to detect a between
group difference in mean neck pain intensity that was as
small as 0.6 points on the 0–10 NRS scale, given the
standard deviations in the sample and an alpha of 0.06.
For all three subgroups, baseline factors were compared
using ANOVA for numerical data and the Chi-square
test for categorical data. At all follow-up time points the
proportions of patients ‘improved’ within each of the 3
groups were compared using the Chi-square test. For
the secondary outcomes of NRS change scores (baseline
score – follow-up score) and BQN change scores the
ANOVA test was used for all follow-up time points as
the data was normally distributed. Using the change
scores rather than the actual outcome scores usually
provides normally distributed data, as in this case,
and thus allows the means and standard deviations to
be reported.
Additionally, treatment outcomes of high acute (0–
2 weeks) vs. midacute (2–4 weeks) as well as midacute
vs. subacute (4–12) neck pain patients were compared
in order to identify whether the midacute patients be-
have more similarly to the high acute or the subacute
patient groups in their treatment response. The Chi-
square test was used for categorical variables (i.e. im-
provement) and the unpaired Student’s t-test was used
for the NRS and BQN change scores.
A p-value ≤0.05 was considered statistically significant.
For all data analysis SPSS Version 21, IBM, Armonk,
New York, USA was used.
Ethics
Written informed consent was obtained from all patients
and ethics approval was obtained from the Canton of
Zürich Switzerland ethics committee (EK 19/2009).
Results
Baseline characteristics
Of the 260 active members of the Association of Swiss
Chiropractors 81 (31%) contributed patients to this
Page 4 of 10
study. Baseline data from 495 patients with symptoms of
12 weeks or less were available and included in this
study. Of these, 274 were highly acute (0–2 weeks of
symptoms), 62 mid-acute (2–4 weeks of symptoms) and
159 subacute (4–12 weeks of symptoms). At the con-
secutive time points at 1 month, 3 months, 6 months
and 1 year after the initial treatment, the numbers of in-
cluded patients vary. This is a result of the limited time
period when each follow-up telephone call was con-
ducted. Some patients could not be reached during the
predefined time frame but remained in the study if data
from other time points was available.
Baseline characteristics for all three subgroups are
shown in Table 1. Significant differences in baseline
characteristics within the 3 subgroups are summarised
in Table 2. Mid-Acute patients were significantly older
than both high-acute as well as subacute patients. No
other significant differences between the high-acute and
mid-acute subgroups were found. Comparing subacute
and mid-acute patients found that subacute patients
were less likely to smoke and reported a significantly
lower baseline NRS score than the mid-acute subgroup.
The subacute patients also had a significantly lower
baseline NRS score than high-acute patients, were sig-
nificantly older than high-acute patients and reported a
lower General Health. Additionally, a significantly higher
percentage of high-acute patients reported a smoking
habit compared to subacute patients.
Outcomes
Improvement on the PGIC scale was the primary out-
come measure of the study. The percentage of patients
‘improved’ amongst the three subgroups is shown in
Fig. 1. The high-acute subgroup had a significantly
higher percentage of ‘improved’ patients compared to
the mid-acute patients only at the 1 week time point
(p = 0.015) (Table 3), whereas the significant differ-
ences between high-acute and subacute patients per-
sisted to the 3 month time point (p = 0.0001 at
1 week and 1 month; p = 0.018 at 3 months) (Table
3 and Fig. 1). Mid-acute patients had significantly bet-
ter outcomes compared to the subacute patients at
both the 1 week (p = 0.039) and 1 month (p = 0.025)
time points. At the 6 month and 1 year time points
significant differences between the 3 subgroups were
no longer found (Table 3).
The secondary outcome data showing the change
scores (baseline value – follow-up value) of NRS (neck),
and the BQN for all outcome time points are shown in
Table 4. Except for the 1 week and 6 months outcome
time points (NRS change), the mid-acute patient sub-
group did not differ significantly from the high-acute
subgroup or the subacute patient subgroup regarding
the investigated patient-reported scores. High-acute and
Nyirö et al. Chiropractic & Manual Therapies (2017) 25:24 Page 5 of 10

Table 1 Comparison of high-acute, mid-acute and subacute neck pain patients’ baseline pain and disability scores as well as
baseline characteristics
High-acute Mid-acute Subacute P-Value
(0–2 weeks) (2–4 weeks) (4–12 weeks)
n = 274 n = 62 n = 159
Pre NRSNeck 6.23 (±2.02) 5.94 (±2.35) 5.41 (±2.30) 0.001*
Mean (SD)
Pre BQ total 33.54 (±15.22) 33.94 (±15.25) 31.10 (±16.38) 0.244
Mean (SD)
Gender Male: 102 (37.2%) Male: 27 (43.5%) Male: 51 (32.1%) 0.255
Female: 172 (62.8%) Female: 35 (56.5%) Female: 108 (67.9%)
Age (years) 38.7 (±12.11) 47.1 (±12.73) 42.8 (±14.54) 0.0001*
Mean (SD)
General Health good: 200 (74.9%) good: 38 (62.3%) good: 93 (59.6%) 0.013*
average: 55 (20.6%) average: 20 (32.8%) average: 55 (35.3%)
poor: 12 (4.5%) poor: 3 (4.9%) poor: 8 (5.1%)
Radiculopathy present (yes) 37 (13.7%) 12 (19.4%) 27 (17.4%) 0.399
Trauma onset (yes) 39 (14.2%) 8 (13.1%) 20 (12.7%) 0.893
Smoker (yes) 59 (22.1%) 14 (23.3%) 18 (11.5%) 0.016*
NRS numerical rating scale for pain, BQ Bournemouth questionnaire, SD Standard Deviation. * = p ≤ 0.05

subacute patient cohorts however, report significantly having a significantly better outcome than subacute pa-
different scores at every time point except at 1 week tients. After 6 months, no further significant differences
(BQ change). were found between the three subgroups. Treatment
outcomes level off at the 6-month follow-up time point
Discussion with more than 86% of the patients in all three sub-
The primary outcome measure of ‘clinically relevant im- groups considered as ‘improved’. Patients with mid-
provement’ in this study only showed a significant differ- acute (2–4 weeks) duration of symptoms showed no sig-
ence between the high-acute patients (0–2 weeks of nificant differences either to the high-acute (0–2 weeks)
symptoms) and mid-acute patients (2–4 weeks of symp- or the subacute (4–12 weeks) subgroups with their pro-
toms) at the data collection time point of 1 week with a portions of patients responding to chiropractic treatment
higher proportion of the high acute patients reporting falling between the high-acute and subacute subgroups.
improvement. There were no further significant differ- Analyzing the secondary outcome measures of the BQ
ences in the primary outcome for the later data collec- and NRS change scores, mid-acute patients also do not
tion time points detected for these two subgroups. Thus differ significantly from either the high-acute subgroup
this is different from the results obtained for the chiro- or the subacute patient subgroup whilst high-acute and
practic low back pain study where there were more sig- subacute patient cohorts report significantly different
nificant differences between the patients in these two scores at almost every time point.
‘acute’ time frames [40]. The results of this study demonstrate a time-dependent
Comparison of mid-acute and subacute neck pain pa- converging of outcomes among the three subgroups. Sta-
tients showed some significant differences at the 1 week tistically significant differences between the high-acute
and 1 month time points, with mid-acute patients still (0–2 weeks) and mid-acute (2–4) subgroups could only be
reported 1 week after start of treatment and thus the clin-
Table 2 P-values obtained when Comparing High-acute vs. ical relevance of this result is negligible. The findings of
Mid-acute, Mid-acute vs. Subacute and High-acute vs. Subacute this study lead to the conclusion that a categorization of
Patients in terms of the Baseline characteristics significant in acute pain according to 0–4 weeks of symptoms should
Table 1 be preferred to the suggested 0–2 weeks of symptoms for
High-acute Mid-acute High-Acute neck pain patients. In current research, the most often
vs. Mid-acute vs. Subacute vs. Subacute
used time frame for acute neck pain uses symptom dur-
Pre NRS Neck 0.322 0.124 0.0001* ation of 0–4 weeks [19].
Age (years) 0.0001* 0.043* 0.002* The findings of this neck pain study are surprisingly
General Health 0.115 0.935 0.003* different from a parallel study on low back pain patients
Smoker (yes) 0.971 0.046* 0.009* in similar Swiss chiropractic settings [40]. Investigating
NRS numerical rating scale for pain, BQ Bournemouth
low back pain patients receiving chiropractic treatment,
questionnaire; * = p ≤ 0.05 Mantel et al. reported significant differences in the
Nyirö et al. Chiropractic & Manual Therapies (2017) 25:24 Page 6 of 10

Fig. 1 Primary outcome: Patients ‘improved’ at given outcome time points

outcome of low back pain patients with 0–2 and 2– pain threshold level for each patient. Thus, determining
4 weeks of symptoms at the time points of 1 week, whether a patient fits into the 0–2 week or 2–4 weeks’
1 month, and 6 months and those authors stated that for time period is not always as precise as we would like to
low back pain patients undergoing chiropractic treatment think. Additionally, the aetiology of neck pain is variable.
that 0–4 weeks of symptoms as the definition of ‘acute’ low This study has its focus on the outcome of chiropractic
back pain is too long and that a definition of 0–2 weeks is patients. Therefore, the individual cause of neck pain may
preferable [40]. vary between neuropathic or nociceptive (mechanical,
OECD (Office for Economic Cooperation and Develop- myofascial etc.) pain. Differences in the baseline character-
ment) guidelines [45] - as well as recommended tools for istics of the three subgroups might be explained through
assessing quality of research [46] request that the study the small number of patients particularly in the 2–4 week
population in a research project should be clearly specified onset group, and different causes of neck pain being un-
and predefined. From a research perspective, the division equally represented in each subgroup. There were no dif-
of patient groups according to their duration of symptoms ferences in recruiting procedure between the subgroups.
depicts a measurable and reproducible way of subgroup- Baseline differences were assessed as well and taken into
ing. However, interpreting clinical outcome data of acute consideration interpreting the clinical outcome. So far, there
neck pain patients bears a major challenge. The entity of is very limited evidence regarding the influence of baseline
neck pain depicts more accurately a symptom than a med- factors on the outcome of neck pain patients [47, 48]. Even
ical condition. In the absence of acute trauma, neck pain though neck pain patients depict a very heterogeneous study
is often a slowly developing condition and the exact time population, current literature suggests a predictive value of
of onset may be difficult to pin point, depending on the certain baseline factors [15, 27, 47, 49]. In a 2007 systematic
review, Mallen et al. note that baseline pain characteristics
(pain intensity, duration, number of previous episodes and
Table 3 P-value Results Comparing the Proportion of Patients
Reporting Clinically Relevant ‘Improvement’ for the 3 different
multiple-site pain), levels of disability and psychological fac-
Chronicity Categories at all time Points tors (anxiety, depression, adverse coping strategies, low so-
High-acute Mid-acute High-Acute
cial support) were all associated with subsequent outcome
vs. Mid-acute vs. Subacute vs. Subacute in musculoskeletal pain [50].
1 week 0.015* 0.039* 0.0001* Comparing the three subgroups in this study, baseline
differences were registered for baseline severity of pain,
1 month 1.000 0.025* 0.0001*
mean age, general health and smoking habit. There were
3 months 0.630 0.420 0.018*
no significant differences detected for the other baseline
6 months 0.284 1.000 0.068 factors including the baseline BQ score, patient gender
1 year 1.00 0.565 0.146 as well as pain onset due to trauma or pain accompanied
* = p ≤ 0.05 with radiculopathy. Several studies report the number of
Nyirö et al. Chiropractic & Manual Therapies (2017) 25:24 Page 7 of 10

Table 4 Comparison of NRS and BQ Change Scores for Patients in the 3 Chronicity Categories at all Follow-up Time Points
Number High-acute (0– Number Mid-acute (2– Number Sub-acute (4– P Values
2 weeks) 4 weeks) 12 weeks)
Mean (SD) Mean (SD) Mean (SD)
Change 220 3.33 (±2.49) 42 2.52 (±2.23) 124 1.66 (±2.28) High-acute vs. Mid-acute: p = 0.053
NRS Mid-acute vs. Subacute: p = 0.035*
Neck High-acute vs. Subacute:
1 week p = 0.0001*
Change 221 8.29 (±14.34) 42 7.47 (±13.98) 125 6.75 (±14.09) High-acute vs. Mid-acute: p = 0.733
BQ total Mid-acute vs. Subacute: p = 0.775
1 week High-acute vs.
Subacute: p = 0.336
Change 224 4.26 (±2.64) 54 3.55 (±2.96) 139 2.83 (±2.63) High-acute vs. Mid-acute: p = 0.086
NRS Mid-acute vs. Subacute: p = 0.098
Neck High-acute vs. Subacute:
1 month p = 0.0001*
Change 223 21.87 (±16.99) 54 18.33 (±18.07) 140 15.65 (±17.53) High-acute vs. Mid-acute: p = 0.177
BQ total Mid-acute vs. Subacute: p = 0.344
1 month High-acute vs. Subacute:
p = 0.001*
Change 223 4.59 (±2.75) 54 4.18 (±2.73) 131 3.30 (±2.92) High-acute vs. Mid-acute: p = 0.324
NRS Mid-acute vs. Subacute: p = 0.061
Neck High-acute vs. Subacute:
3 months p = 0.0001*
Change 221 25.54 (±16.40) 54 24.36 (±17.13) 132 19.14 (±19.17) High-acute vs. Mid-acute: p = 0.637
BQ total Mid-acute vs. Subacute: p = 0.084
3 months High-acute vs. Subacute:
p = 0.001*
Change 227 4.93 (±2.47) 52 3.95 (±2.56) 132 3.31 (±2.61) High-acute vs. Mid-acute:
NRS p = 0.012*
Neck Mid-acute vs. Subacute: p = 0.136
6 months High-acute vs. Subacute:
p = 0.0001*
Change 192 18.74 (±16.04) 38 17.34 (±14.47) 109 11.54 (±16.58) High-acute vs. Mid-acute: p = 0.618
BQ total Mid-acute vs. Subacute: p = 0.058
6 months High-acute vs. Subacute:
p = 0.0001*
Change 216 4.91 (±2.60) 49 4.17 (±2.63) 127 3.41 (±2.78) High-acute vs. Mid-acute: p = 0.073
NRS Mid-acute vs. Subacute: p = 0.101
Neck High-acute vs. Subacute:
1 year p = 0.0001*
Change 216 26.41 (±17.03) 49 22.56 (±16.49) 128 19.42 (±16.50) High-acute vs. Mid-acute: p = 0.151
BQ total Mid-acute vs. Subacute: p = 0.260
1 year High-acute vs. Subacute:
p = 0.0001*
SD Standard Deviation, NRS Numerical rating scale for pain, BQ Bournemouth questionnaire; * = p < 0.05

previous episodes as one of the most valuable predictive
factors for outcome [27, 30, 47, 49]. However, this was
not assessed in this study as that data was previously
published [30].
From the 3 subgroups evaluated in this study, both
high-acute and mid-acute patients were more likely to
smoke than subacute patients. Smoking might be a risk
factor for the development or exacerbation of pain.
Long-time smoking may sensitize pain receptors, decrease
pain tolerance, increase pain perception, and has been
shown to contribute to pain persistence [51–57].
Additional differences were found between the high-
acute and subacute patients. High-acute patients reported
a higher severity of pain on the NRS scale than subacute
patients. However, these pain levels were obtained upon
presentation for treatment and not at the actual onset of
symptoms. The difference in baseline pain severity in the
high-acute subgroup is most likely an effect of natural his-
tory within the acute pain phase [58].
The last difference in the baseline characteristics com-
paring these 3 subgroups of neck pain patients found
that a significantly higher number of patients reported
below average health in the subacute group. This may
correspond to the results of other studies which report
an association between faster recovery and better general
health [6, 59, 60].
Nyirö et al. Chiropractic & Manual Therapies (2017) 25:24
It is conceivable that subgrouping according to the dur-
ation of symptoms remains an artificial and somehow arbi-
trary way of categorization amongst a very heterogeneous
acute neck pain population. The definition of acute and
chronic pain by duration of symptoms is predicated on the
assumption that acute pain signals a potential tissue damage,
whereas chronic pain results from central as well as periph-
eral sensitization where pain is sustained after nociceptive
inputs have diminished [61, 62].
Implications for future research
Subgrouping patients by means of symptom duration
appears to be an easy and objective way of categorisa-
tion. However, duration-based definitions can be difficult
to apply in terms of recurrent pain or pain with gradual
onset. For multiple reasons, current research criticises
pain definition solely by duration, suggesting pain to be
a multi-dimensional concept [5, 47, 62, 63]. To embrace
the complex and multi-dimensional concept of neck
pain, we recommend for future research the use of ei-
ther multidimensional or multiple categorisation criteria
additional to the duration of symptoms as suggested by
The Bone and Joint Decade 2000–2010 Task Force on
Neck Pain and Its Associated Disorders [64].
Limitations
There are limitations to this study. This is not a random-
ized clinical trial but a prospective cohort observational
study. As there is no control group in this study, outcomes
of the patients cannot be definitely attributed to the treat-
ment but may correspond with the natural course of heal-
ing process within the acute pain phase [58].
Baseline information for this study was collected using
paper questionnaires. However, follow-up data was col-
lected via telephone interviews. Multiple studies have
detected a false positive effect on outcomes with patients
being more likely to report more favourable outcome to
the interviewer [63, 65, 66]. Even though the telephone
interviews were conducted by anonymous research assis-
tants at the university, unknown to the patients, these
effects cannot be excluded.
An important limitation to this study is the smaller sam-
ple size in the mid-acute patient group. Additionally, not
every patient could be reached at the different follow up
time points, especially at the follow up time point 1 week
post treatment resulting in there being fewer patients be-
cause of the narrow time window allowed. As this was a
secondary analysis on data previously collected for another
study, power calculations to determine an adequate sample
size for the 2–4 week subgroup were not done prior to data
analysis as no additional patients could be included.
It is also not known what proportion of patients asked
to participate in this study by their treating chiropractor
actually agreed to participate.
Page 8 of 10
Although the use of the Bournemouth questionnaire
may appear to be a limitation in this study due to the
fact it only contains 7 subscales, previous studies have
found it to be a reliable and valid instrument and more
responsive to change compared to the Neck Disability
Index and the Neck Pain and Disability Scale [42, 67].
Conclusion
The time period with 0–4 weeks of symptoms as the
definition of “acute” neck pain should be maintained. Pa-
tients with a shorter period (0–2 weeks) of symptoms
recover faster than patients with a longer period of
symptoms (2–4 weeks) but this difference is only statisti-
cally significant at the 1 week and 1 month time periods.
These results for neck pain patients are different from
those obtained in the similar study investigating acute
low back pain patients where the 0–2 weeks time period
as the definition of ‘acute’ was recommended. Medium-
term and long-term outcome is favourable for acute as
well as subacute neck pain patients, independent of the
exact duration of symptoms.
Abbreviations
BQ: Bournemouth questionnaire; BQN: Bournemouth questionnaire for neck
pain; NDI: Neck disability index; NPAD: Neck pain and disability scale;
NRS: Numerical pain rating scale; OECD: Organization for Economic
Cooperation and Development; PGIC: Patient’s Global Impression of Change Scale
Acknowledgements
Not applicable.
Funding
Funding for this study was provided from the Balgrist Hospital Stiftung, the
Unisciencia foundation and the European Academy of Chiropractic.
Availability of data and materials
The SPSS data set is available through the Chiropractic Medicine Department,
Orthopaedic University Hospital, University of Zürich, Switzerland.
Authors’ contributions
LN: Literature search, data analysis and interpretation of data, drafting and
revising the manuscript. CP: Ethics approval submission, data entry, data
interpretation, revising the manuscript, final approval of the manuscript. BKH:
Concept and design of the study, manuscript review and revision, final approval
of the manuscript. All authors read and approved the final manuscript.
Ethics approval and consent to participate
Written informed consent was obtained from all patients and ethics approval was
obtained from the Canton of Zürich Switzerland ethics committee (EK 19/2009).
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Nyirö et al. Chiropractic & Manual Therapies (2017) 25:24
Received: 21 April 2017 Accepted: 24 July 2017
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